MEDICARE: DR. NICOLE ANN STOREY OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	009212	NY
2	152WP0200X	Pediatric Optometrist	009212	NY

General Provider Information

NPI Number	:	1962023796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLE ANN STOREY OD

Provider Business Mailing Address
First Line	:	920 ALBANY SHAKER RD STE 101
Second Line	:
City	:	LATHAM
State	:	NY
Zip	:	12110-1468
Country	:	US
Telephone Number	:	518-533-6502
Fax Number	:	518-533-6505

Provider Business Practice Location Address
First Line	:	920 ALBANY SHAKER RD STE 101
Second Line	:
City	:	LATHAM
State	:	NY
Zip	:	12110-1468
Country	:	US
Telephone Number	:	518-533-6502
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2020
Last Update Date	:	11/08/2020

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